Kansas Emergency Medical Services Education Standards EMERGENCY MEDICAL RESPONDER

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Kansas Emergency Medical Services

Education Standards

EMERGENCY MEDICAL

RESPONDER

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Contents

Preparatory EMS Systems (PR1) Page 5

Preparatory Research (PR2) Page 7

Preparatory Workforce Safety and Wellness (PR3) Page 8

Preparatory Documentation (PR4) Page 14

Preparatory EMS System Communication (PR5) Page 15

Preparatory Therapeutic Communication (PR6) Page 16

Preparatory Medical/Legal Ethics (PR7) Page 17

Preparatory Anatomy and Physiology (PR8) Page 21

Preparatory Medical Terminology (PR9) Page 23

Preparatory Pathophysiology (PR10) Page 24

Preparatory Life Span Development (PR11) Page 25

Preparatory Public Health (PR12) Page 27

Pharmacology Principles of Pharmacology (PR13) Page 28

Pharmacology Medication Administration (PR14) Page 29

Pharmacology Emergency Medications (PR15) Page 31

Airway Mgmt Restoration and Artificial Vent Airway Management (AM1) Page 32

Airway Mgmt Restoration and Artificial Vent Respiration (AM2) Page 35

Airway Mgmt Restoration and Artificial Vent Artificial Ventilation (AM3) Page 39

Patient Assessment Scene Size-Up (PA1) Page 43

Patient Assessment Primary Assessment (PA2) Page 46

Patient Assessment History-Taking (PA3) Page 50

Patient Assessment Secondary Assessment (PA4) Page 55

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Patient Assessment Reassessment (PA6) Page 64

Medicine Medical Overview (MT1) Page 66

Medicine Neurology (MT2) Page 67

Medicine Abdominal and Gastrointestinal Disorders (MT3) Page 69

Medicine Immunology (MT4) Page 71

Medicine Infectious Disease (MT5) Page 72

Medicine Endocrine Disorders (MT6) Page 73

Medicine Psychiatric (MT7) Page 75

Medicine Cardiovascular (MT8) Page 78

Medicine Toxicology (MT9) Page 80

Medicine Respiratory (MT10) Page 83

Medicine Hematology (MT11) Page 84

Medicine Genitourinary/Renal (MT12) Page 85

Medicine Gynecology (MT13) Page 86

Medicine Non-Traumatic Musculoskeletal Disorders (MT14) Page 87

Medicine Diseases of the Eyes, Ears, Nose, and Throat (MT15) Page 88

Shock and Resuscitation (ST1) Page 89

Trauma Trauma Overview (ST2) Page 93

Trauma Bleeding (ST3) Page 96

Trauma Chest Trauma (ST4) Page 98

Trauma Abdominal and Genitourinary Trauma (ST5) Page 99

Trauma Orthopedic Trauma (ST6) Page 100

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Trauma Head, Facial, Neck, and Spine Trauma (ST8) Page 106

Trauma Nervous System Trauma (ST10) Page 108

Trauma Special Considerations in Trauma (ST11) Page 109

Trauma Environmental Emergencies (ST12) Page 111

Trauma Multi-System Trauma (ST13) Page 116

Special Patient Populations Obstetrics (SP1) Page 117

Special Patient Populations Neonatal Care (SP2) Page 120

Special Patient Populations Pediatrics (SP3) Page 122

Special Patient Populations Geriatrics (SP4) Page 126

Special Patient Populations Patients with Special Challenges (SP5) Page 128

EMS Ops Principles of Safely Operating a Ground Ambulance (OP1) Page 129

EMS Operations Incident Management (OP2) Page 131

EMS Operations Multiple Casualty Incidents (OP3) Page 132

EMS Operations Air Medical (OP4) Page 134

EMS Operations Vehicle Extrication (OP5) Page 136

EMS Operations Hazardous Materials Awareness (OP6) Page 139

EMS Ops Mass Cal Incidents Due to Terrorism and Disaster (OP7) Page 140

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Preparatory

EMS Systems (PR1)

EMR Education Standard

Uses knowledge of the Emergency Medical Services (EMS) system, safety/well-being of the Emergency Medical Responder (EMR), and medical/legal issues at the scene of an emergency.

EMR-Level Instructional Guideline

I. The Emergency Medical Services (EMS) System

A. The Current EMS Systems 1. Types of systems in EMS

a. Fire-based

b. Third party service c. Hospital-based

2. Delivery may be different but the goal is the same – based upon community needs/resources B. National Highway Traffic Safety Administration (NHTSA) Is Lead Coordinating Agency

C. Access to the Emergency Medical Services 1. Public Safety Access Point (PSAP) 2. Most communities access through 9-1-1 D. Education

1. National Scope of Practice Model a. Description of the profession b. Prehospital personnel levels 2. National EMS Education Standards E. Authorization to Practice

1. State EMS office

a. Determines scope of practice

b. Licenses/certifies prehospital personnel 2. Medical oversight

a. Protocols

b. Quality improvement c. Administrative 3. Local credentialing

4. Employer policies and procedures

II. Roles, Responsibilities, and Professionalism of EMS Personnel A. Roles and Responsibilities

1. Maintain equipment readiness 2. Safety

a. Personal b. Patient

c. Others on scene

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4. Gain access to the patient 5. Perform patient assessment

6. Administer emergency medical care while awaiting arrival of additional resources 7. Provide emotional support

a. Patient

b. Patient family c. Other responders d. Bystanders

8. Maintain continuity of care a. Definition

b. EMR is the first step in the EMS care ladder

9. Maintain medical and legal standards and assure patient privacy 10. Maintain community relations

B. Professionalism

1. Characteristics of professional behavior a. Integrity

b. Empathy c. Self-motivation

d. Appearance and hygiene e. Self-confidence f. Knowledge of limitations g. Time management h. Communications i. Teamwork j. Respect k. Tact l. Patient advocacy

m. Careful delivery of care 2. Maintaining certification a. Personal responsibility b. Continuing education c. Skill competency d. Criminal implications e. Fees

III. Quality Improvement

A. Dynamic System for Continually Evaluating and Improving Care 1. Patient safety

2. Significant – one of the most urgent health care challenges 3. How errors happen

a. Skills/knowledge-based failure b. Rules-based failure

4. How you can help reduce errors a. Debrief calls

b. Constantly question assumptions c. Use decision aids/Ask for help

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Preparatory

Research (PR2)

EMR Education Standard

Uses knowledge of the EMS system, safety/well-being of the EMR, and medical/legal issues at the scene of an emergency.

EMR-Level Instructional Guideline

I. Impact of Research on EMR Care

A. Research Findings Are Important to Identify What Should Be Changed in EMS Assessment and Management and to Improve Patient Care and Outcome

B. Quality Assurance Research for an EMS System Can Improve Service Delivery C. Data Collection

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Preparatory

Workforce Safety and Wellness (PR3)

EMR Education Standard

Uses knowledge of the EMS system, safety/well-being of the EMR, and medical/legal issues at the scene of an emergency.

EMR-Level Instructional Guideline

I. Standard Safety Precautions

A. Baseline Health Assessment

1. Before working in health care, complete a physical examination to determine health status 2. Immunizations should be current while practicing in health care

a. Tetanus b. Hepatitis B

c. Measles/mumps/rubella (German measles) d. Chicken pox (varicella)

e. Influenza

3. Screening for tuberculosis may be required locally B. Hand washing

C. Adherence to Standard Precautions/OSHA Regulation D. Safe Operation of EMS/Patient Care Equipment E. Environmental Control

F. Occupational Health and Blood borne Pathogens 1. Immunizations

2. Sharps

II. Personal Protective Equipment

A. Standard Precautions Reduce the Risk of Exposure to Diseases Spread Through Blood or Body Fluids or by Respiratory Droplets

B. Standard Precautions 1. Hand hygiene

a. The most important measure to prevent the spread of infection b. Wash your hands after gloves are removed

c. Hand cleansing i. soap and water

ii. alcohol-based hand rub

d. Cleanse hands with soap, and dry thoroughly

e. Cleanse hands and other exposed skin immediately after exposure to blood and body fluids or after personal use of the toilet

2. Gloves

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b. If latex allergy is concern, use an alternative type of glove 3. Eye protection or face shield

a. Goggles or full-face shield

b. Use if risk of splash or spray of blood or body fluids

i. goggles reduce risk of contamination of eyes; full-face shield reduces risk of contamination of eyes, nose, or mouth

ii. use for care of patients who are a) bleeding profusely b) delivering a baby c) vomiting

d) coughing up sputum

e) have urinated or defecated on self 4. Masks

a. High-efficiency particulate air (HEPA) or N95 mask for EMR b. Surgical mask for patient

5. Gown

a. Disposable gowns should be worn if there is a potential for large amounts of blood or body fluids

b. If clothing becomes contaminated i. remove as soon as possible ii. shower as soon as possible

iii. do not wash contaminated clothes with other personal or family clothing iv. preferably complete i-iii at work

6. Sharps (needles, lancets) C. If an exposure occurs

1. Clean contaminated area thoroughly with soap and water

2. If eyes are involved, flush with water for a minimum of 20 minutes 3. Report exposure to the EMS providers who take over care of the patient

4. Report exposure to appropriate person identified in your department infection control plan 5. Seek immediate follow-up care as identified in your department infection control plan 6. Document

a. Time and date of exposure b. Circumstances of exposure c. Actions taken after exposure

d. Other information required by your agency D. Soiled equipment, sharps, or vehicles

1. Cleaning 2. Disinfection 3. Disposal II. Stress Management

A. Many EMS Situations Can Be Stressful for EMS Personnel 1. Dangerous situations

2. Physical and psychological demands 3. Critically ill or injured patients 4. Dead and dying patients

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5. Overpowering sights, smells, and sounds 6. Multiple-patient situations

7. Angry or upset patients, family, and bystanders B. EMR Should Be Supportive

C. During and Immediately After a Stressful Incident 1. Administer appropriate medical care 2. Cooperate with other personnel

a. Law enforcement b. Other EMS providers

c. Other emergency responders (i.e., fire, utilities, etc.) 3. Be calm, supportive, and nonjudgmental

4. Allow patients to express feelings, unless behavior is harmful to themselves or others D. Recognize the Warning Signs of Personal Stress

1. Difficulty sleeping and nightmares

2. Irritability with coworkers, family, and friends 3. Feelings of sadness, anxiety, or guilt

4. Indecisiveness 5. Loss of appetite

6. Loss of interest in sexual activity 7. Isolation

8. Loss of interest in work 9. Physical symptoms 10. Feelings of hopelessness

11. Alcohol or drug misuse or abuse 12. Inability to concentrate

E. Strategies to Manage Personal Stress 1. Talk about your feelings 2. See a professional counselor

3. Lifestyle changes can reduce stress a. dietary changes

b. limit caffeine and alcohol intake c. exercise

d. use relaxation techniques F. Dealing with Death and Dying

1. Attempt to resuscitate patients without a pulse or not breathing unless:

a. Do Not Resuscitate (DNR) order that meets local guidelines is presented at scene b. Obvious signs of death are present

i. tissue decay (putrefaction) ii. rigor mortis

a) stiffening of joints that occurs after death b) assess two or more joints to verify iii. injuries not compatible with life

c. Attempting resuscitation would endanger your life 2. How to assist grieving patients or family members

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a. Responses to death and dying are very individual

b. The following may be experienced in any order or some may not be experienced at all i. denial

ii. anger

a) patient/family projects anger toward others, especially to whom they are closest

b) do not take anger personally, even though it may seem directed at you c) be alert to anger that may become physical and endanger you or others iii. bargaining

a) patient/family may attempt to negotiate with a spiritual being or EMS providers in an effort to extend life

b) be non-judgmental iv. depression

a) patient or family exhibits sadness and grief

b) affected person is usually withdrawn, sad, and may cry continually c) allow affected person to express feelings and help to understand these are normal feelings associated with death

v. acceptance

a) patient/family accepts situation and incorporates experience into the activities of daily living in an effort to survive

b) use good listening skills and a non- judgmental attitude in this phase III. Prevention of Response-Related Injuries

A. Exposure to Infectious Diseases

1. How infectious diseases are spread a. Through the air by coughing

b. Direct contact with infected blood or body fluid c. Needle sticks

d. Contaminated food e. Sexually transmitted 2. Exposure

a. Contact with blood or body fluids of a person with an infectious disease i. patient’s blood gets into a cut on your hand or a hangnail

ii. you are stuck with a needle used by a patient iii. bloody saliva splashes into your eyes or mouth

b. Close contact with a person with an airborne disease (e.g., influenza, tuberculosis, etc.) B. Injury Prevention

1. Good personal habits a. Sleep

b. Nutrition

c. Current immunization status d. Fitness

2. Safe response to vehicle collisions a. Traffic hazards

b. Deployment of air bags c. Power lines

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e. Other hazards i. fire

ii. leaking fluids

f. Violent or potentially violent persons g. Risk factors for violence

h. Safe response i. law enforcement ii. awareness iii. restraint 3. Hazardous material a. Definition

b. Assess the scene for signs of hazardous materials if suspected i. binoculars

ii. look for placards iii. notify dispatch

c. Do not approach the scene if you suspect a hazardous material release i. remain uphill and upwind a safe distance from the scene ii. await specialized resources

IV. Lifting and Moving Patients A. Body Mechanics

1. Keep back straight, arms close to body 2. Maintain a firm grip on stretcher or patient 3. Avoid twisting of the body

4. Maintain firm footing

5. Communicate next move clearly to partner or team 6. Use good posture

B. Know Your Own Physical Limitations 1. Safe lifting of cots and stretchers

a. Power lift b. Squat lift 2. Carrying

a. Determine the weight to be lifted b. Communicate with partner or team c. Keep the weight close to your body d. Flex at hips and bend at knees, not waist 3. Reaching

a. General guidelines

b. Correct reaching for log rolling 4. Pushing and pulling techniques

C. Emergency Moves

1. Immediate danger to the patient a. Fire or danger of fire

b. Close proximity of explosives or other imminent hazards c. To gain access to others who need lifesaving care

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2. Types of emergency moves

a. Pull toward the long axis of the body if possible b. Clothing drag

c. Blanket drag d. Firefighter’s drag e. Firefighter’s carry 3. Urgent moves

a. Patients with altered mental status b. Inadequate breathing or shock

c. Other situations potentially dangerous to the patient 4. Techniques

a. Direct ground lift b. Extremity lift

c. Moving patients from a bed to stretcher i. direct carry

ii. draw sheet D. Positioning Patients

1. Position of comfort a. Indications for use b. Techniques 2. Recovery position

a. Indications for use b. Techniques 3. Supine

a. Indications for use b. Techniques E. Restraint

1. Consider medical or trauma as cause for altered mental status 2. Restrain only if patient is a danger to self or others

a. When using restraints have police present if possible b. Get approval from medical direction

c. Follow local protocols 3. If restraints must be used:

a. Have adequate help/Plan your activities b. Use only the force necessary for restraint

c. Estimate range of motion of patient’s arms and legs and stay beyond range until ready d. Once decision has been made, act quickly

e. Have one EMR talk to patient throughout restraining

f. Approach with four persons, one assigned to each limb, all at the same time g. Secure limbs with equipment approved by medical direction

h. Never secure a patient face down – have access to the airway at all times i. Consider the use of oxygen by non-rebreather mask

j. Reassess airway, breathing, and circulation frequently

k. Document indication for restraining patient and technique of restraint l. Avoid unnecessary force

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Preparatory

Documentation (PR4)

EMR Education Standard

Uses knowledge of the EMS system, safety/well-being of the EMR, and medical/legal issues at the scene of an emergency.

EMR-Level Instructional Guideline

I. Recording Patient Findings

A. Prehospital Care Report 1. Functions 2. Continuity of care 3. Administrative 4. Legal B. Document 1. Time of events 2. Assessment findings

3. Emergency medical care provided 4. Changes in the patient after treatment 5. Observations at the scene

6. Disposition

a. Refused care

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Preparatory

EMS System Communication (PR5)

EMR Education Standard

Uses knowledge of the EMS system, safety/well-being of the EMR, and medical/legal issues at the scene of an emergency.

EMR-Level Instructional Guideline

I. Communications

A. Call for Resources B. Transfer Care of Patient

1. When other EMS personnel arrive on scene, identify yourself and give a verbal report a. Current patient condition

b. Patient’s age and gender c. Chief complaint

d. Brief, pertinent history of what happened e. How you found the patient

f. Major past illnesses g. Vital signs

h. Pertinent findings of the physical exam

i. Emergency medical care given and response to care C. Interact Within the Team Structure

1. Communicate issues concerning the patient and scene to a. Law enforcement

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Preparatory

Therapeutic Communication (PR6)

EMR Education Standard

Uses knowledge of the EMS system, safety/well-being of the EMR, and medical/legal issues at the scene of an emergency.

EMR-Level Instructional Guideline

I. Principles of Communicating with Patients in a Manner That Achieves a Positive Relationship A. Factors for Effective Communication

1. Introduction a. Self b. Partners/team c. Patient introduction 2. Privacy 3. Interruptions 4. Physical environment a. Lighting

b. Noises and outside interference c. Distracting equipment

d. Distance

e. Equal seating, eye level 5. Note-taking

B. Interviewing Techniques 1. Using questions

a. Open-ended questions b. Closed or direct questions c. One question at a time

d. Choose language the patient understands 2. Hazards of interviewing

a. Providing false assurance or reassurance b. Giving advice

c. Leading or biased questions d. Talking too much

e. Interrupting

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Preparatory

Medical/Legal and Ethics (PR7)

EMR Education Standard

Uses knowledge of the EMS system, safety/well-being of the EMR, and medical/legal issues at the scene of an emergency.

EMR-Level Instructional Guideline

I. Consent

A. Conditions for Consent

1. Decision-making capacity a. Intellectual capacity

b. Age of majority (18 years old in most States) c. Ability to make decisions

d. May be impaired in cases of i. intoxication (alcohol/drugs) ii. serious injury or illness iii. mental incompetence iv. legal incompetence B. Expressed

1. Patient gives permission for care a. Informed consent

b. Understanding implications of actions C. Implied

1. Inability to consent arising from medical condition 2. Pediatrics

D. Emancipated Minor

1. Civil rights obtained by person below age of majority (i.e. marriage) 2. Economic self-sufficiency

3. Military service E. Pediatrics

1. Parental control

2. Courts assume parental control F. Refusal of Care

1. Patients with decision-making capacity of legal age have a right to refuse care 2. Follow local policies related to refusal of care

3. If care is refused, tell the patient a. Treatment that is needed i. why it is needed ii. alternative treatments b. Risks of refusing care

c. That EMS may be called again if the patient changes their decision d. Follow local protocols related to refusal under supervision of EMR 4. Notify

a. Responding EMS providers

b. Medical direction (if required in your local policies) 5. Document the refusal according to local policy

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a. Have patient sign refusal documentation

b. Have witness sign refusal document to patient’s signature II. Confidentiality

A. Obligation to Protect Patient Information

B. Health Information Portability and Accountability Act (HIPAA) 1. Description

2. Protected health information (PHI) a. Identifies the patient

b. Relates to physical health, mental health, and treatment c. Can be written or verbal

3. Permitted disclosures of PHI without written patient consent a. Treatment, payment, and operations

b. Special situations

i. mandatory reporting ii. public health

iii. law enforcement (specific situations only) iv. certain legal situations

III. Advanced Directives/End of Life Issues

A. Do Not Attempt Resuscitation (DNAR) Order 1. Terminal disease

2. Medical futility (as discussed in the current International Liaison Committee on Resuscitation [ILCOR] consensus statement)

3. Limited resuscitation B. Living Wills

1. Advance directives indicating a patient’s wishes 2. May not address the EMR in your State

C. Surrogate Decision-Makers

1. Durable power of attorney for healthcare 2. Healthcare proxy

3. Next of kin D. Organ donation IV. Types of Court Cases

A. Civil (Tort)

1. Abandonment 2. Negligence

a. A failure to follow the standard of care causes or worsens the patient’s injury or illness. i. Four elements must be proven

a) duty to act b) breach of duty

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ii) failure to provide care needed iii) performed care incorrectly c) harm (damage to patient)

d) proximate causation 3. Abandonment B. Criminal 1. Assault 2. Battery V. Evidence Preservation

A. Emergency medical care of the patient is the EMR’s priority

B. Do not disturb any item at the scene unless emergency medical care requires C. Observe and document anything unusual at the scene

D. Do not cut through bullet or knife holes in clothing

E. Work closely with appropriate law enforcement authorities VI. Statutory Responsibilities

A. Scope of Practice 1. Definition

2. Authority to practice (Medical Practice Act as applicable) 3. Professional responsibility

4. Duties to patient, medical director, and public 5. Government and medical oversight

a. Intended to protect public b. Role of medical oversight

i. on-line medical direction ii. off-line medical direction VII. Mandatory reporting

A. Varies by State

B. Follow State requirements

C. Legally Compelled to Notify Authorities 1. Abuse or neglect (child, elder, domestic) 2. Some infectious diseases

3. Certain crimes

D. Legal Liability for Failure to Report E. Fully Document Objective Findings

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VIII. Ethical Principles A. Defined

1. Morals – concept of right and wrong

2. Ethics – branch of philosophy or study of morality 3. Applied ethics – use of ethical values

B. Decision-Making Models 1. Do no harm 2. In good faith

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Anatomy and Physiology (PR8)

EMR Education Standard

Uses knowledge of anatomy and physiology of the upper airway, heart, vessels, blood, lungs, skin, muscles, and bones as the foundation of emergency care.

EMR-Level Instructional Guideline

I. Anatomy and Body Functions

A. Standard Anatomic Terms

1. Patient-oriented directions (patient’s left and patient’s right) 2. Anterior and posterior

3. Midline, medial, lateral, inferior, superior 4. Distal, proximal

B. Skeletal System 1. Components

a. Skull/Face b. Vertebral column

c. Thorax – Ribs and Breastbone d. Pelvis e. Upper extremities f. Lower extremities 2. Joints C. Muscular System 1. Function D. Respiratory System 1. Upper airway a. Nose b. Mouth/teeth c. Tongue/jaw d. Throat/pharynx e. Voice box/larynx f. Epiglottis 2. Lower airway a. trachea/windpipe b. bronchi

c. lungs and bronchioles d. alveoli

3. Structures that support ventilation a. chest wall b. diaphragm c. intercostal muscles 4. Function a. ventilation b. respiration

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c. alveolar/capillary gas exchange E. Circulatory System 1. Heart a. chambers b. coronary arteries 2. Blood vessels a. arteries b. veins c. capillaries 3. Blood

a. red blood cells b. other blood cells c. plasma

4. Function

a. blood flow

b. tissue/cell gas exchange c. blood clotting F. Skin 1. Structures a. epidermis b. dermis c. subcutaneous layer 2. Functions of the skin

a. protection

b. temperature control II. Life Support Chain

A. Fundamental Elements 1. Oxygenation

a. Alveolar/capillary gas exchange b. Cell/capillary gas exchange 2. Perfusion

a. Oxygen b. Glucose

c. Removal of carbon dioxide and other waste products

3. Cells need oxygen and glucose to make energy to perform their functions B. Issues Impacting Fundamental Elements

1. Composition of ambient air 2. Patency of the airway 3. Mechanics of ventilation 4. Regulation of respiration 5. Transport of gases 6. Blood volume

7. Effectiveness of the heart as a pump 8. Blood vessel size and resistance III. Age-Related Variations for Pediatrics and Geriatrics

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Medical Terminology (PR9)

EMR Education Standard

Uses medical and anatomical terms.

EMR-Level Instructional Guideline

I. Medical Terminology

A. Recognizes Simple Medical Prefixes, Suffixes, and Combining Words Such As 1. Cardio- 2. Neuro- 3. Hyper- 4. Hypo- 5. Naso- 6. Oro- 7. Arterio- 8. Hemo- 9. Therm- 10. Vaso- 11. Tachy- 12.

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Brady-Pathophysiology (PR10)

EMR Education Standard

Uses knowledge of shock and respiratory compromise to respond to life threats.

EMR-Level Instructional Guideline

I. Respiratory Compromise

A. Impaired Airway, Respiration, or Ventilation 1. Airway

a. Movement of oxygenated air into and out of lungs is blocked b. Possible causes

i. foreign body airway obstruction ii. tongue in unconscious patient iii. blood or secretions

iv. swelling

v. trauma to the neck 2. Respiration

a. Inadequate oxygen breathed in b. Possible causes

i. low oxygen environment ii. poison gases

iii. infection of the lungs

iv. illness or disease that narrows the airway and causes wheezing v. excess fluid in the lungs

vi. excess fluid between the lungs and blood vessels vii. poor circulation

3. Ventilation

a. Rate or depth of breathing is not adequate

b. Insufficient volume of air moved in and out of lungs c. Possible causes

i. unconscious or altered level of consciousness ii. injury to the chest

iii. poisoning or overdose iv. diseases

II. Shock

A. Impaired Blood Flow to the Organs and Cells 1. Heart

a. Rate is too slow or very fast b. Contractions are too weak

c. Related to heart disease, poisoning, excessive rate, or depth of artificial ventilation 2. Blood vessels

a. Unable to constrict

b. Related to neck fractures with spinal cord injury, infection, or anaphylaxis 3. Blood

a. Decrease in the amount of blood or blood components in the blood vessels b. Related to bleeding, vomiting, diarrhea, or burns

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Life Span Development (PR11)

EMR Education Standard

Uses knowledge of age-related differences to assess and care for patients.

EMR-Level Instructional Guideline

I. Infancy (Birth to 1 Year) A. Physiology

1. Vital signs

a. Normal heart rate in newborns is between 140-160

b. Normal respiratory rate in newborns is 40-60 and drops to 30-40 after 1st few minutes of life

c. Average systolic blood pressure increases from 70mmHg at birth to 90mmHg at 1 year

2. Weight

a. Normally 3.0-3.5 kg at birth 3. Pulmonary system

a. Airways more easily obstructed

b. Infants primarily nose breathers until 4 weeks

c. Rapid respiratory rates lead to rapid heat and fluid loss 4. Nervous system

a. Strong, coordinated suck and gag reflexes b. Well flexed extremities

c. Extremities move equally when infant is stimulated II. Toddler (12 to 36 Months) and Pre-School Age (3 to 5)

A. Physiological 1. Vital signs

a. Normal heart rate is 80-130 beats per minute in toddlers and 80-120 beats/minute in preschool-age children

b. Normal respiratory rate is 20-30 breaths/minute in toddlers and preschool-age children c. Normal systolic blood pressure is 70-100mmHg in toddlers and 80-110mmHg in preschool-

age children

d. Normal temperature is 96.8 - 99.6 degrees Fahrenheit 2. Nervous system

III. School-Age Children (6 to 12) A. Physiological

1. Vital signs

a. Normal heart rate is 70 - 110 beats per minute b. Normal respiratory rate is 20 - 30 breaths per minute c. Normal systolic blood pressure is 80 - 120 mmHg d. Normal temperature is 98.6 degrees Fahrenheit 2. Bodily functions

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IV. Adolescence (13 to18) A. Physiological

1. Normal heart rate is 55 - 105 beats per minute 2. Normal respiratory rate is 12 - 20 breaths per minute 3. Normal systolic blood pressure is 80 - 120 mmHg V. Early Adulthood (20 to 40)

A. Physiological

VI. Middle Adulthood (41 to 60) A. Physiological

1. Normal heart rates average 70 beats per minute

2. Normal respiratory rate average 16 to 20 breaths per minute 3. Normal blood pressure average 120/80 mmHg

4. Vision and hearing become less effective 5. Cardiovascular health becomes a concern 6. Cancer strikes in this age group often 7. Weight control becomes more difficult

8. Menopause in women in late forties and early fifties B. Psychological

1. Approach problems more as challenges than threats 2. Empty-nest syndrome

3. Often burdened by financial commitments to elderly parents and young adult children VII. Late Adulthood (61 and Older)

A. Physiological

1. Normal vital signs are dependent on the patient’s physical and health status 2. Cardiovascular function changes

a. Circulation efficiency decreases b. Tachycardia not well tolerated c. Functional blood volume decreases 3. Respiratory system

a. Chest wall weakens

b. Gas exchange through alveoli is diminished c. Lung capacity is diminished

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Public Health (PR12)

EMR Education Standard

Has knowledge of local public health resources and the role EMS personnel play in public health emergencies.

EMR-Level Instructional Guideline

I. Basic Principles of Public Health

A. EMS Interface With Public Health 1. EMS is a public health system

a. EMS provides a critical public health function b. Collaborations with other public health agencies 2. Roles for EMS in public health

a. Health prevention and promotion

i. primary prevention-preventing disease development a) vaccination

b) education

ii. secondary prevention-preventing complications and/or progression of disease iii. health screenings

b. Disease surveillance

i. EMS providers are first line care givers

ii. patient care reports may provide information on epidemics of disease 3. Injury prevention

a. Safety equipment b. Education

i. car seat safety ii. seat belt use iii. helmet use

iv. driving under the influence v. falls

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Pharmacology

Principles of Pharmacology (PR13)

EMR Education Standard

Uses knowledge of the medications that the EMR may self-administer; administer to a peer; or administer to or assist a patient in taking, in an emergency situation.

EMR-Level Instructional Guideline

I. Medication safety

II. Kinds of Medications Used in an Emergency

A. Forms of Medication administered or assisted administration by the EMR 1. Solid

a. Tablets – compressed powders b. Powder – inhalation

2. Liquids

a. Enteral (ingested) b. Parenteral (injected) 3. Gases; aerosols – inhalation B. Routes of Medication Administration

1. Enteral (ingested)

a. Sublingual (e.g., nitroglycerin) b. Oral (e.g., glucose)

2. Parenteral (injected and inhaled) a. Inhaled (e.g., oxygen) b. Injection (e.g., epinephrine) c. Methods of injection

i. intramuscular-auto injector III. Basic Medication Terminology

A. Drug Name 1. Generic 2. Trade B. Drug Profile

1. Actions

a. Pharmacodynamics – impact of age and weight upon medication administration b. Indication c. Intended effects 2. Contraindications 3. Side effects 4. Dose 5. Route

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Pharmacology

Medication Administration (PR14)

EMR Education Standard

Uses knowledge of the medications that EMR may self-administer; administer to a peer; or administer to or assist a patient in taking, in an emergency.

EMR-Level Instructional Guideline

I. Self-Administration (Intramuscular Injection by Auto injector) A. Advantages

B. Disadvantages C. Techniques

II. Peer Administration (Intramuscular Injection by Auto injector) A. Advantages

B. Disadvantages C. Techniques

III. Assist/Administer Medications to a Patient

A. Administration versus Assistance of Medications

1. Assisting patients in taking prescribed medications 2. Administering medication

3. Medical Direction

a. Off-line; standing orders, written protocols b. On-line; verbal order

a) Confirmation – echo technique b) Confusion – clarification B. Medication Administration Procedure

1. The ―rights‖ of drug administration

a. Right patient – prescribed to patient b. Right medication – patient condition c. Right route – patient condition d. Right dose – prescribed to patient e. Right time – within expiration date C. Techniques of Medication Administration

1. Oral

a. Advantages b. Disadvantages c. Techniques

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2. Sublingual/Buccal a. Advantages b. Disadvantages c. Techniques

3. Intramuscular injection by Auto injector a. Advantages b. Disadvantages c. Techniques 4. Inhalation a. Advantages b. Disadvantages c. Techniques D. Reassessment

1. Data – indications for medication 2. Action – medication administered 3. Response – effect of medication E. Documentation

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Pharmacology

Emergency Medications (PR15)

EMR Education Standard

Uses knowledge of the medications that the EMR may self-administer; administer to a peer; or administer to or assist a patient in taking, in an emergency.

EMR-Level Instructional Guideline

The EMR must know names, effects, indications, routes of administration, and dosages for all of the following emergency medications.

I. Specific Medications (i.e. Chemical Antidote Auto injector Devices) A. EMR – Administer Medications

1. Aspirin – with Medical Direction ONLY 2. Oral glucose

3. Oxygen

4. Epinephrine - Auto injector B. EMR – Assisted Medications

1. Metered dose inhaled bronchodilators 2. Nitroglycerin

a. tablets b. spray C. EMR – Self & Peer

1. Mark I 2. Duo Dote

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Airway Management, Respiration, and Artificial Ventilation

Airway Management (AM1)

EMR Education Standard

Applies knowledge (fundamental depth, foundational breadth) of anatomy and physiology to assure a patent airway, adequate mechanical ventilation, and respiration for patients of all ages.

EMR-Level Instructional Guideline

I. Airway Anatomy

A. Upper Airway Tract 1. Nose

2. Mouth and oral cavity

a. Alternate airway, especially in emergency b. Entrance to the digestive system

c. Also involved in the production of speech d. Tongue 3. Jaw 4. Throat/pharynx a. Oropharynx b. Epiglottis c. Larynx/voice box i. vocal cords ii. thyroid cartilage iii. cricoid cartilage B. Lower Airway Tract

1. Trachea/windpipe

a. Hollow tube which passes air to the lower airways b. Supported by cartilage rings

2. Bronchi

a. Hollow tubes which further divide into lower airways of the lungs b. Supported by cartilage

3. Lungs

a. Bronchioles

i. thin hollow tubes leading to the alveoli ii. remain open through smooth muscle tone b. Alveoli

i. the end of the airway

ii. millions of thin walled sacs

iii. each alveolus surrounded by capillary blood vessels

iv. site where oxygen and carbon dioxide (waste) are exchanged II. Airway Assessment

A. Signs of Adequate Airway

1. Airway is open, can hear and feel air move in and out 2. Patient is speaking in full sentences

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B. Signs of Inadequate Airway

1. Unusual sounds are heard with breathing (i.e. stridor or snoring) 2. Awake patient is unable to speak or voice sounds hoarse

3. No air movement 4. Apnea 5. Airway obstruction a. Tongue b. Food c. Vomit d. Blood e. Teeth f. Foreign body

C. Swelling Due to Trauma or Infection

III. Techniques of Assuring a Patent Airway (refer to current American Heart Association guidelines) A. Manual Airway Maneuvers

1. Head tilt/chin lift a. Purpose b. Indications c. Contraindications d. Complications e. Procedure f. Limitation 2. Jaw thrust maneuver

a. To open airway when cervical spine injury is suspected b. Procedure

c. If jaw thrust maneuver does not work, use head tilt/chin lift maneuver 3. Modified chin lift

a. Purpose b. Indications c. Contraindications d. Complications e. Procedure f. Limitation B. Mechanical Airway Devices

1. Oropharyngeal a. Purpose b. Indications c. Contraindications d. Complications e. Procedure f. Limitation 2. Nasopharyngeal a. Purpose b. Indications c. Contraindications

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d. Complications e. Procedure f. Limitation

C. Relief of Foreign Body Airway Obstruction (refer to current American Heart Association guidelines) D. Upper Airway Suctioning

1. Purpose 2. Indications 3. Contraindications 4. Complications

5. Procedure - soft and rigid suction catheters a. mechanically powered suction devices

i. purpose ii. indication iii. contraindications iv. complications v. procedure vi. limitation b. hand-powered suction i. purpose ii. indication iii. contraindications iv. complications v. procedure vi. limitation

c. bulb syringe – Meconium Aspiration ONLY i. purpose ii. indication iii. contraindications iv. complications v. procedure vi. limitation 6. Limitation

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Airway Management, Respiration, and Artificial Ventilation

Respiration (AM2)

EMR Education Standard

Applies knowledge (fundamental depth, foundational breadth) of anatomy and physiology to assure a patent airway, adequate mechanical ventilation, and respiration for patients of all ages.

EMR-Level Instructional Guideline

I. Anatomy of the Respiratory System

A. Includes All Airway Anatomy Covered in the Airway Management Section B. Additional Respiratory System Anatomy

1. Chest cage (includes ribs and muscles) a. Intercostal muscles

b. Diaphragm

C. Vascular Structures That Support Respiration 1. Pulmonary capillaries

a. Picks up oxygen from the alveoli

b. Releases carbon dioxide (waste) to the alveoli 2. Heart and blood vessels

a. Circulates unoxygenated blood to lungs to pick up oxygen

b. Circulates oxygenated blood from lungs though heart to cells of the body II. Physiology of Respiration

A. Pulmonary Ventilation

1. Ventilation is defined as the movement of air into and out of the lungs

2. Patients with adequate ventilation are moving normal or near-normal volumes of air B. Oxygenation

1. Refers to the amount of oxygen dissolved in blood and body fluids

2. Blood that is almost fully saturated with oxygen is described as well-oxygenated blood C. Respiration

1. The process by which the body captures and uses oxygen and disposes of carbon dioxide 2. External respiration

3. Internal respiration 4. Cellular respiration

a. Each cell of the body performs a specific function

b. Oxygen and sugar are essential to produce energy for cells to perform their function c. Produce carbon dioxide as a waste product

III. Pathophysiology of Respiration A. Pulmonary Ventilation

1. Interruption of nervous control a. Drugs

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b. Trauma

c. Muscular dystrophy 2. Structural damage to the thorax 3. Bronchoconstriction

4. Disruption of airway patency a. Infection

b. Trauma/burns

c. Foreign body obstruction d. Allergic reactions

e. Unconsciousness (loss of muscle tone) B. Oxygenation

C. Respiration

1. External respiration

a. Deficiencies due to closed environments

b. Deficiencies due to toxic or poisonous environments 2. Internal respiration

3. Cellular respiration

a. Ineffective Circulation i. shock

ii. cardiac arrest

IV. Assessment of Adequate/Inadequate Respiration (refer to current American Heart Association Guidelines) A. Unresponsive Patient

1. Medical patients

a. Open and maintain the airway using head-tilt, chin-lift technique 2. Trauma patients

a. Open and maintain airway using modified jaw thrust technique while maintaining manual cervical stabilization

B. Responsive Patient

1. If the patient speaks, the airway is functional but may still be at risk

a. Foreign body or substances in the mouth may impair the airway and must be removed i. finger sweep (solid objects)

ii. suction (liquids)

2. If upper airway becomes narrowed, inspiration may produce a high-pitched whistling sound known as stridor

a. Foreign body b. Swelling c. Trauma

3. Airway patency must be continually reassessed 4. Breathing status

a. Normal adult breathing b. Abnormal adult breathing

i. characteristics

a) the respiratory rate is too fast or too slow for the age of the patient ii. management

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a) administer oxygen to all patients with abnormal breathing

b) consider assisting breathing with bag-mask and supplemental oxygen if i) unresponsive

ii) skin is blue (cyanotic) in color c) rate issues

i) breathing is too fast for the age of the patient ii) breathing is too slow for the age of the patient

(a) verbal/painful stimulus increases rate to normal? (b) assist with bag-mask and supplemental oxygen

(c) treat patients, occasionally gasping, as if not breathing iii) breathing is absent

iv) assist ventilation with pocket mask or bag-mask with supplemental oxygen

d) bag-mask ventilations administered via airway adjuncts inserted by higher trained attendants

i) blind insertion airway adjuncts ii) endotracheal tubes

iii. chest rise and fall is shallow iv. breathing is noisy

a) gurgling noise without secretions in the mouth b) wheezing

v. effort of breathing

a) accessory muscles i) neck

ii) between ribs iii) abdomen b) nasal flaring c) tripod position V. Management of Adequate and Inadequate Respiration

A. Assure Patent Airway (techniques described in Airway Management section) B. Techniques for Assuring Adequate Respirations

VI. Supplemental Oxygen Therapy A. Portable Oxygen Cylinder

1. Cylinder size

a. D – 350 liters b. E – 625 liters 2. Regulators

3. Assembly and use of cylinders 4. Changing a cylinder

a. Safe residual for operation is 200 psi 5. Securing and handling cylinders

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B. Oxygen Delivery Devices 1. Nasal cannula a. Purpose b. Indications c. Procedure d. Limitation 2. Non-Rebreather (NRB) Mask a. Purpose b. Indications c. Procedure d. Limitation 3. Partial Rebreather Mask

a. Purpose b. Indications c. Procedure d. Limitation 4. Simple Face Mask

a. Purpose b. Indications c. Procedure d. Limitation

5. Blow by Oxygen Therapy a. Purpose b. Indications c. Procedure d. Limitation 6. Humidifers a. Purpose b. Indications c. Procedure d. Limitation

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Airway Management, Respiration, and Artificial Ventilation

Artificial Ventilation (AM3)

EMR Education Standard

Applies knowledge (fundamental depth, foundational breadth) of anatomy and physiology to assure a patent airway, adequate mechanical ventilation, and respiration for patients of all ages.

EMR-Level Instructional Guideline

I. Assessment of Adequate and Inadequate Ventilation

A. Adequate

1. Respiratory rate is normal 2. Respiration depth is normal 3. Effort of breathing is normal B. Inadequate

1. Abnormal work (effort) of breathing

a. Muscles between ribs pull in on inhalation b. Nasal flaring

c. Excessive use of abdominal muscles to breath d. Sweating

e. Sitting upright and leaning forward (tripod position) f. Fatigue from work of breathing

2. Abnormal breathing sounds a. Stridor

b. Wheezing heard when patient breathes 3. Depth of breathing a. Shallow b. Markedly increased 4. Rate of breathing a. Very slow b. Very fast

5. Chest wall movement or damage a. Paradoxical

b. Splinting c. Penetrating d. Asymmetric

6. Irregular respiratory pattern II. Oxygenation

A. Adequate

1. Mental status considered normal for patient 2. Skin color normal

B. Inadequate

1. Ambient air is abnormal a. Enclosed space b. High altitude

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c. Poison gas

2. Mental status considered abnormal or altered for patient 3. Skin color/mucosa is not normal

a. Cyanosis b. Pallor c. Mottling

III. Management of Adequate and Inadequate Ventilation A. Patients with Adequate Ventilation

B. Patients with Inadequate Ventilation 1. May be conscious or unconscious

2. Assist ventilation during respiratory distress/failure a. Pocket mask

i. purpose ii. indications iii. procedure iv. limitation

v. pocket mask with oxygen outlet a) advantages

b) oxygen flow rate b. Bag-valve-mask with reservoir

i. purpose ii. indications iii. procedure iv. limitation v. indications a) apnea b) cardiac arrest vi. procedure

a) see manufacturer’s instructions for the specific device b) explain the procedure to the patient

c) place the mask over the patient’s nose and mouth

d) initially assist at the rate at which the patient has been breathing e) squeeze the bag each time the patient begins to inhale

f) adjust the rate and the delivered tidal volume vii. limitations

a) requires oxygen

b) difficult to maintain adequate mask seal with one rescuer operation c) must have bag-valve-mask device available

d) may interfere with timing of chest compressions during CPR e) must monitor to assure full exhalation

f) inadequate mask seal

g) difficult to accomplish in combative/hypoxic patients c. Barrier device

i. purpose ii. indications iii. procedure

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iv. limitation d. Mouth to mouth i. purpose ii. indications iii. procedure iv. limitation e. Mouth to nose i. purpose ii. indications iii. procedure iv. limitation f. Mouth to stoma i. purpose ii. indications iii. procedure iv. limitation

g. Sellick’s maneuver (cricoid pressure)

i. use during positive pressure ventilation ii. reduces amount of air in stomach iii. procedure

a) identify cricoid cartilage

b) apply firm backward pressure to cricoid cartilage with thumb and index finger

iv. do not use if

a) patient is vomiting or starts to vomit b) patient is responsive

c) breathing tube has been placed by advanced level providers IV. Ventilation of an Apneic Patient

A. To Oxygenate and Ventilate the Patient B. Indications

1. No breathing is noted

2. Occasional gasping breathing is noted C. Monitoring Patient

D. Limitation

V. Differentiate Normal Ventilation from Positive Pressure Ventilation A. Air Movement

1. Normal ventilation

a. Creates negative pressure inside the chest b. Air is sucked into lungs

2. Positive pressure ventilation with pocket mask or bag-mask B. Blood Movement

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1. Normal ventilation

a. Blood returns to the heart from the body

b. Blood is pulled back to the heart during normal breathing 2. Positive pressure ventilation

a. Blood return to the heart is decreased when lungs are inflated b. Less blood is available for the heart to pump

c. Amount of blood pumped out of the heart is reduced C. Esophageal Opening Pressure

1. Normal ventilation

a. Esophagus remains closed during normal breathing b. No air enters the stomach

2. Positive pressure ventilation with a pocket mask or bag-mask a. Air is pushed into the stomach during ventilation b. Excess air in stomach may lead to vomiting

D. Excess rate or depth of ventilation using pocket mask or bag-mask can harm patient. Ventilating too fast or too deep may cause decreased blood pressure, vomiting, or decreased blood flow when the chest is compressed during CPR

(43)

Patient Assessment

Scene Size-Up (PA1)

EMR Education Standard

Use scene information and patient assessment findings to identify and manage immediate life threats and injuries within the scope of practice of the EMR.

EMR-Level Instructional Guideline

I. Scene Safety

A. Common Scene Hazards 1. Environmental 2. Hazardous substances a. Chemical b. Biological 3. Violence a. Patient b. Bystanders c. Crime scenes 4. Rescue a. Motor-vehicle collisions i. extrication hazards

ii. roadway operation dangers b. Special situations

B. Evaluation of the Scene 1. Is the scene safe?

a. Yes -- establish patient contact and proceed with patient assessment. b. No -- is it possible to quickly make the scene safe?

i. Yes – assess patient

ii. No -- do not enter any unsafe scene until minimizing hazards c. Request specialized resources immediately

II. Scene Management

A. Impact of the Environment on Patient Care 1. Medical

a. Determine nature of illness b. Hazards at medical emergencies 2. Trauma

a. Determine mechanism of injury b. Hazards at the trauma scene 3. Environmental considerations

a. Weather or extreme temperatures b. Toxins and gases

c. Secondary collapse and falls d. Unstable conditions

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B. Addressing Hazards 1. Protect the patient

a. After making the scene safe, the safety of the patient becomes the next priority

b. If conditions cannot be alleviated that represent a health or safety threat to the patient, move the patient to a safer environment

2. Protect the bystanders

a. Minimize conditions that represent a hazard for bystanders

b. If hazards cannot be minimized, remove bystanders from the scene 3. Request resources

a. Multiple patients need additional ambulances b. Fire hazard need fire department

c. Traffic or violence issues need law enforcement 4. Scan the scene for information related to

a. Mechanism of injury b. Nature of the illness C. Violence

1. EMRs should not enter a scene or approach a patient if the threat of violence exits

2. Park away from scene and wait for appropriate law enforcement officials to minimize danger D. Need for Additional or Specialized Resources

1. A variety of specialized protective equipment and gear is available for specialized situations a. Chemical and biological suits can provide protection against hazardous materials and biological threats of varying degrees

b. Specialized rescue equipment may be necessary for difficult or complicated extrications

c. Ascent or descent gear may be necessary for specialized rescue situations 2. Only specially trained responders should wear or use the specialized equipment E. Standard Precautions

1. Overview

a. Principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents

b. Includes prevention practices that apply, regardless of infection status c. Universal precautions were developed for protection of healthcare personnel d. Standard precautions focus on protection of patients

2. Implementation

a. The extent of standard precautions used is determined by anticipated exposure i. hand washing

ii. gloves iii. gowns iv. masks

v. protective eyewear 3. Personal protective equipment

a. Personal protective equipment provides limited protection b. Wear PPE appropriate for the potential hazard

i. steel-toe boots ii. helmets

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iv. self-contained breathing apparatus v. leather gloves

F. Multiple-Patient Situations

1. Number of patients and need for additional support a. How many patients?

b. Does the dispatch suggest the need for additional support? c. Protection of the patient

i. weather or extreme temperatures ii. unstable conditions

d. Protection of bystanders i. remove

ii. isolate iii. barricade 2. Need for additional resources

a. Incident Command System (ICS or IMS)

(46)

Patient Assessment

Primary Assessment (PA2)

EMR Education Standard

Use scene information and patient assessment findings to identify and manage immediate life threats and injuries within the scope of practice of the EMR.

EMR-Level Instructional Guideline

I. Primary Survey/Primary Assessment

A. Primary Survey Quickly Attempts to Identify Conditions That Represent an Immediate Threat to the Patient’s Life

B. Initial General Impression – Based on the Patient’s Age-Appropriate Appearance 1. Appears stable

2. Appears stable but potentially unstable 3. Appears unstable Level of Consciousness C. Level of Consciousness

1. While approaching or making contact with the patient, establish level of consciousness a. Speak to the patient and determine the level of response

b. EMR should identify himself or herself

c. EMR should explain that he or she is there to help 2. Patient response

a. Alert

i. the patient appears to be awake

ii. the patient acknowledges the presence of the EMR b. Responds to verbal stimuli

i. the patient opens his/her eyes in response to the EMR’s voice ii. the patient responds appropriately to a simple command c. Responds to painful stimuli

i. the patient does not acknowledge presence or EMR nor respond to loud voice ii. patient responds only when the EMR applies some form of irritating stimulus

a) irritating stimulus should cause the patient to either attempt to move away from the stimulus or attempt to move the stimulus away from them b) acceptable irritating stimuli

i) pinch the patient’s ear ii) trapezius squeeze iii) others

d. Unresponsive (patient does not respond to any stimulus) C. Airway Status (refer to the current American Heart Association Guidelines)

1. Unresponsive patient a. Medical patients

i. open and maintain the airway with head-tilt, chin-lift technique

ii. see the current American Heart Association guidelines for steps in performing this procedure for victims of all ages

(47)

b. Trauma patients

i. open and maintain airway with modified jaw thrust technique while maintaining manual cervical stabilization

ii. see the current American Heart Association guidelines for the steps in performing this procedure for victims of all ages

2. Responsive patient

a. If patient speaks, airway is functional but may still be at risk – foreign body or substances in the mouth may impair the airway and must be removed

i. finger sweep (solid objects) ii. suction (liquids)

b. If upper airway becomes narrowed, inspiration may produce a high-pitched whistling sound known as stridor

i. foreign body ii. swelling iii. trauma

c. Airway patency must be continually reassessed D. Breathing Status

1. Patient responsive

a. Breathing is adequate (rate and quality)

i. breathing will produce a visible chest rise and fall ii. breathing will be quiet (non-noisy)

iii. the adult will not be expending much energy to breath b. Breathing is too fast ( >24 breaths per minute)

c. Breathing is too slow (<8 breaths per minute) d. Breathing absent (choking)

2. Patient unresponsive

a. Breathing is adequate (rate and quality) b. Breathing is inadequate

c. Breathing is absent 3. Abnormal adult breathing

a. Characteristics b. Management

i. administer oxygen to all patients with abnormal breathing

ii. consider assisting breathing with a bag-mask with supplemental oxygen if a) unresponsive

b) skin is blue (cyanotic) in color iii. rate issues

a) breathing is too fast for the age of the patient b) breathing is too slow for the age of the patient

i) does verbal or painful stimulus increase the rate to normal? ii) assist breathing with a bag-mask with supplemental oxygen iii) treat occasionally gasping patients as if they were not breathing c) breathing is absent

i) assist ventilation with a pocket mask or bag-mask with supplemental oxygen

c. Chest rise and fall is shallow d. Breathing is noisy

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ii. wheezing e. Effort of breathing i. accessory muscles a) neck b) between ribs c) abdomen ii. nasal flaring iii. tripod position E. Circulatory Status

1. Is a radial pulse present? a. Yes

i. normal - adult heart rate 60-100/min ii. fast - adult heart rate > 100/min iii. slow - adult heart rate < 60/min iv. irregular rate

b. Radial pulse absent – assess for carotid pulse

i. if carotid pulse present, lay patient flat and elevate feet 8-12 inches ii. no carotid pulse, begin CPR

2. Is any major bleeding present? a. Yes – control the bleeding b. No

3. Is the patient maintaining adequate blood flow (perfusion status) a. Skin color (assess palms of hands in dark-skinned patients)

i. pink

ii. pale skin may indicate a) low body temperature b) blood loss

c) shock (poor blood flow) d) poor blood flow to a body part iii. blue (cyanotic skin) may indicate

a) problem with airway, ventilation, respiration b) poor blood flow

b. Skin temperature

i. cool skin may indicate

a) low body temperature b) shock

c. Skin moisture

i. dry or slightly moist

ii. wet or sweaty skin may indicate a) physical exertion

b) severe pain c) shock d. Capillary refill (children)

i. press on the skin and release

ii. color should return to area depressed within two seconds iii. color return in more than two seconds may indicate shock 4. Treat for shock in primary survey if

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b. Heart rate too fast or too slow c. Skin signs of shock are present 5. Management of shock

a. Administer oxygen by non-rebreather mask at 15 liters per minute (if available) b. Lay patient flat

F. Identifying Life Threats

1. Assess patient and determine if the patient has a life-threatening condition a. Unstable: treat life-threatening condition is found – treat immediately b. Stable: assess nature of illness or mechanism of injury

G. Assessment of Vital Functions

II. Integration of Treatment/Procedures Needed to Preserve Life III. Evaluating Priority of Patient Care and Transport

A. Primary Assessment: Stable

B. Primary Assessment: Potentially Unstable C. Primary Assessment: Unstable

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Patient Assessment

History-Taking (PA3)

EMR Education Standard

Use scene information and patient assessment findings to identify and manage immediate life threats and injuries within the scope of practice of the EMR.

EMR-Level Instructional Guideline

I. Mechanism of Injury or Nature of Illness

A. Mechanism of Injury

1. Forces that caused an injury

2. May help predict presence of injuries B. Nature of Illness

1. Ask patient, family, or bystanders why EMS was called 2. Look for clues in environment

a. Hot or cold environment b. Presence of drugs or poisons II. Determining the Chief Complaint

A. The Chief Complaint Is a Very Brief Description of the Reason for Summoning EMS to the Scene 1. The patient may be able to answer all questions about their own chief complaint and history 2. If not, this information may be obtained from

a. Family/Friends b. Bystanders

c. Public safety personnel

d. Medical identification jewelry or other medical information sources 3. How reliable is the data?

B. History of the Present Illness

1. Detailed evaluation of the chief complaint

2. Provides a full, clear, chronological account of the signs and symptoms C. Associated Signs and Symptoms

1. Ask the Patient to Describe the Current Problem

a. Sign – any medical or trauma finding that can be seen, felt, or heard by the EMR i. Listening to blood pressure

ii. Seeing an open wound iii. Feeling skin temperature

b. Symptom – any condition that is described to the EMR by the patient i. ―I’m having trouble breathing‖

ii. ―I have a headache‖ iii. ―My chest hurts‖ D. Events Leading to the Illness or Injury

(51)

III. Components of a Patient History A. Statistical and Demographic

1. Obtain and accurately document all dates and times 2. Identifying data

a. Age b. Gender

c. Race/Ethnicity

B. Past Medical History (pertinent to the Medical Event) 1. Medical, trauma, surgical

2. Consider medical identification tag

C. Current Health Status (Pertinent to the Medical Event) 1. Focuses on present state of health

2. Environmental conditions 3. Individual factors

a. Current medications b. Allergies

c. Tobacco use

d. Alcohol, drugs, and related substances e. Diet

f. Screening tests g. Immunizations

h. Environmental hazards

i. Use of safety measure (in and out of the home) j. Family history

IV. Techniques of History Taking A. Setting the Stage

1. Environment – personal space

2. EMS personnel demeanor and appearance a. Be aware of body language

b. Clean, neat, and professional 3. Note-taking

a. Difficult to remember all details

b. Most patients comfortable with note-taking B. Learning About the Present Illness

1. Refer to the patient by name

a. Refer to the patient by their last name with the proper title i. Mr., Mrs., or Ms.

ii. if they inform you to address them by their first name, do so

b. Avoid the use of unfamiliar or demeaning terms such as ―granny‖ or ―honey‖ C. Determine Chief Complaint

1. Use a general, open-ended question 2. Follow the patient’s lead

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a. Facilitation

i. posture, actions, or words should encourage the patient to say more

ii. making eye contact or saying phrases such as ―go on‖ or ―I’m listening‖ may help the patient to continue

b. Reflection

i. repeating the patient’s words encourages additional responses

ii. typically does not bias the story or interrupt the patient’s train of thought c. Clarification – used to clarify ambiguous statements or words

d. Empathetic responses – use techniques of therapeutic communication to interpret feelings and your response

e. Confrontation – may require you to confront patients about their feelings f. Interpretation – goes beyond confrontation, requires you to make an inference D. History of the Present Illness

1. Location (where is it?) 2. Onset (when did it start?)

3. Provocation, palliative, and positioning a. What makes it worse?

b. What makes it better?

c. What position is the patient comfortable? 4. Quality (what is it like?)

5. Radiation (does it move anywhere?) 6. Severity

a. Attempt to quantify the pain b. Utilize the scale, 1-10 7. Time

a. Duration

b. When did it start? c. How long does it last? 8. Associated signs and symptoms 9. Pertinent negative(s)

10. For trauma patients, determine the mechanism of injury E. Assess Past Medical History (Pertinent to the Medical Event)

1. Pre-existing medical conditions or surgeries 2. Medications

3. Allergies 4. Family history

5. Social history; travel history F. Current Health Status

1. Tobacco use

2. Use of alcohol, drugs, and other related substances 3. Diet

IV. Standardized Approach to History-Taking A. SAMPLE History

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2. A = Allergies a. Medication b. Environmental 3. M = Medications

a. Over the counter (OTC) b. Prescribed

c. Vitamins and herbal

d. Birth control / erectile dysfunction e. Other people’s medication

f. Recreational drugs

4. P = Past pertinent medical history – relevant information concerning the illness or injury 5. L = Last oral intake

a. Fluids b. Food

c. Other substances

6. E = Events leading to the illness or injury

a. What were you doing just prior to the illness or injury? B. OPQRST History

1. O = Onset – time the signs or symptoms started 2. P = Provocative, palliative, and positioning

a. What makes it worse? b. What makes it better? c. Positioning

i. in what position is the patient found? ii. should the patient remain in that position? 3. Q = Quality of the discomfort

a. Patient’s ability to describe the type of discomfort i. burning

ii. stabbing iii. crushing 4. R = Radiation

a. Does the discomfort move in any direction? 5. S = Severity

a. Pain scale 6. T = Time

a. Relating to onset, however, more definitive in regards to initial onset in the history V. Taking History on Sensitive Topics

A. Alcohol and Drugs

B. Physical Abuse or Violence C. Sexual History

D. Special Challenges 1. Silent patient

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b. Be alert for nonverbal clues of distress

c. Silence may be the result of the interviewer’s lack of sensitivity 2. Overly talkative patients

a. Give the patient free reign for the first several minutes b. Summarize frequently

3. Patient with multiple symptoms 4. Anxious patient

a. Anxiety is natural

b. Be sensitive to nonverbal clues c. Reassurance

5. Angry and hostile patient

a. Understand that anger and hostility are natural b. Often the anger is displaced toward the EMR c. Do not get angry in return

6. Intoxicated patient

a. Be accepting, not challenging

b. Do not attempt to have patient lower voice or stop cursing; this may aggravate them c. Avoid trapping them in small areas

d. Treat with dignity, despite their intoxication 7. Crying patient may provide valuable insight

8. Depressed patient

a. Be alert for signs of depression

b. Be willing to listen and be non-judgmental 9. Patient with confusing behavior or history

10. Patient with limited cognitive abilities

a. Do not overlook the ability of these patients to provide you with adequate information b. Be alert for omissions

11. EMR-patient language barrier-take every possible step to find a translator

12. Patient with hearing problem – if patient can write, have them write questions and answers on paper

13. Patient with visual impairment – always announce your presence and provide careful explanations of everything you are doing

14. Talking with family and friends

a. Some patients may not be able to provide you with all information b. Try to find a third party who can help you get the whole story VI. Age-Related Variations for Pediatric and Geriatric Assessment and Management

A. Pediatric

1. Assess infant pulse at brachial artery

2. Capillary refill is a reliable assessment of adequate blood flow in infants and children < six 3. Use distracting measures to gain trust

4. See Special Patient Population section (Pediatrics) B. Geriatric

1. Obtain eye glasses and hearing aids 2. Expect history to take more time

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